The Pharmaceutical Journal Vol 267 No 7166 p380
22 September 2001

This article
Reprint
Photocopy

Comment

An alternative view of the future of the community pharmacy

By Richard Schmidt

The article compiled by Matthew Young of the Adam Smith Institute (PJ, 11 August, p199) seeks to propose that pharmacists should be moved out from community pharmacies into health centres where they will take over the role of prescribing from general practitioners. The basis for this proposal seems to derive from the assertion that “substantial anecdotal evidence suggests that inappropriate prescribing, poor patient compliance and system inefficiencies probably result in a waste of half the pharmacy budget — perhaps £3-£4bn”. The remainder of the article attempts to provide arguments in support of the proposal.

The case presented appears to be seriously flawed.

Evidence of waste through inappropriate prescribing, poor patient compliance, and “system inefficiencies” is anecdotal. Evidence to support or refute this assertion could and should be collected before any major reorganisation of the role of community pharmacists is foisted upon the profession. Indeed, evidence for waste because of poor patient compliance probably exists already in the medicoscientific literature and this should have been abstracted and used by the Adam Smith Institute to validate (or otherwise) their thoughts. This evidence may well be sufficient to support the development of medicines management schemes.

No evidence is presented in support of the assertion that GPs fail to ask themselves whether they are prescribing the correct medication. In my experience, GPs do almost invariably provide apparently rational reasons for their choice of medication when challenged to do so. Much of what appears to be GP prescribing is actually prescribing by proxy on behalf of a hospital consultant. These consultants are, one would imagine, specialists whose prescribing is driven by experience and pragmatism, and their decisions are no doubt made following input from clinical pharmacists where such teamwork exists.

Although as a pharmacist I have dispensed countless prescriptions and would consider myself an authority on medicines, I have essentially no experience of observing outcomes in patients who receive those medicines. I would certainly not presume to suggest that GPs prescribe irrationally, because I have no access to the diagnoses upon which their decisions are based and no feedback relating to outcomes in response to medication. I would therefore challenge the Adam Smith Institute to explain how it reached the conclusion that inappropriate prescribing by GPs may be wasting several billion pounds a year. The article acknowledges the advice provided by unnamed “pharmacists and pharmaceutical companies, academic and policymakers”. So, which of these groups advised the Adam Smith Institute on this matter?

It is implicit in the model proposed by the Adam Smith Institute that diagnosis by the GP will culminate, in effect, in the passing of a note to the prescribing pharmacist upon which will be written the name of a disease or disorder. Unless prescribing pharmacists have the same level of knowledge of pathology as GPs, then this model will not work.

The Adam Smith Institute model proposes that prescribing pharmacists will initially establish prescribing protocols with GPs (and presumably also with prescribing nurses), and will then be limited in their prescribing to a class of drugs specified by the GP. Although it is eminently sensible to have an experienced pharmacist’s input into prescribing, I find it difficult to understand what there is to be gained by having the pharmacist assume the role of prescriber once prescribing protocols are in place. This would in any case interfere with the doctor-patient relationship, a factor that the Adam Smith Institute has completely ignored. Human patients are not automatons, diagnosis is not an exact science and response to prescribed medication is not entirely predictable. Indeed, the response to medication is used to help refine the diagnosis, so to whom does the patient return if the prescribed medication fails to produce the expected outcome? Has any input been sought from practising medical practitioners?

The Adam Smith Institute asserts that “pharmacists are looking for a more professional role because their traditional role of dispenser in community ... pharmacies has changed dramatically”. I am afraid that I simply do not recognise the model of pharmacy past and present that is being described. Yes, there is now virtually no extemporaneous dispensing, but we have instead a greater throughput of a wider selection of medicines in a greater variety of presentations for a larger population of patients. The patients in turn have a greater inclination to self-medicate with a wider selection of food supplements, herbal remedies, and the like, and at the same time have a greater tendency to non-compliance with prescribed medication. I would argue that there is now a greater need than ever for pharmaceutical input at the point of delivery of medicines to the patient. It is simply naive to suggest that an electronic prescription delivered to a robotic dispensing machine manned by a down-graded “associate pharmacist” represents a vision of an improved community pharmacy service.

I could go on. But to be constructive, here is an alternative vision for the profession of pharmacy.

Clinical pharmacy should become a specialty within medicine (PharmD), providing a postgraduate qualification for pharmacy graduates. Greater input from this new improved breed of clinical pharmacy specialists into the prescribing process in hospitals will deliver many of the outcomes envisaged by the Adam Smith Institute.

Existing pharmacy schools should continue to produce pharmacists for hospital and community dispensaries and for research, development, pharmaceutical formulation and other careers in industry. Clinical pharmacy should continue to be taught to the extent necessary to understand drug action and use in a clinical setting.

NHS funding should be found to provide all GP practices and health centres with practice pharmacists, who will be experienced practising community pharmacists and whose function will be to develop prescribing protocols for doctors and nurses, and to develop and co-ordinate medicines management schemes. Their role in the community will be analogous to the role of clinical pharmacy specialists in hospitals. This role would include the control of repeat prescribing and hence review of patients’ ongoing medication needs, and the measurement of treatment outcomes. This would deliver the remainder of the outcomes envisaged by the Adam Smith Institute.

None of these developments will require that the role of the community pharmacist be downgraded; indeed, they represent a way of making better use of existing skills that community pharmacists possess. In view of the fact that the Adam Smith Institute does not appear to appreciate how community pharmacy functions currently, it should be assumed that its argument for downgrading community pharmacy is similarly flawed.

Dr Schmidt is a pharmacist from Barnoldswick, Lancashire